INTRODUCTION
The success rate and the time needed to achieve vascular access are crucial in emergency patients. The traditional method for vascular access is an intravenous (IV) catheter. In emergency situations, the placement of an IV catheter is not feasible. For instance, it may be challenging to establish IV access in dehydrated or hemodynamically unstable patients. The failure rates of IV access reported in the emergency setting range from 10% to 40%.[1,2,3] The procedure time of peripheral intravenous (PIV) catheterization is reported to be 2.5-13.0 minutes, and sometimes even up to 30 minutes for patients in whom establishing peripheral veins is difficult.[1,2,3,4] This additional time can lead to treatment delay.
Intraosseous (IO) access is an alternative method. The current guidelines recommend IO access in adults if peripheral venous access is unavailable under emergency circumstances. In 1986, the American Heart Association formally approved IO infusion in pediatric emergency resuscitation procedures. The European Resuscitation Council recommends that IO access can be established in pediatric and adult emergency patients if it is difficult or impossible to establish peripheral venous access for cardiopulmonary resuscitation (CPR).[5,6] Since 2009, the Chinese guidelines for CPR recommend that IO access could be established if it is impossible to establish PIV access for CPR.[7] Furthermore, several guidelines recommend the use of IO access.
However, most medical staff in China are not aware of IO access, and will choose central venous catheterization (CVC) if it is difficult or impossible to establish PIV access. A survey on a professional medical rescue team showed that only 19.8% of medical staff knew about IO access.[8] In another study, when the medical staff failed to achieve peripheral venous access twice, 22.1% (93/420) of them would try the peripheral venous puncture again, 70.7% (297/420) would consider CVC, and only 4.1% (17/420) would try IO access.[9]
In order to obtain data on IO access in China, we conducted a single-center study. The study showed that the success rate of the first attempt of the IO access was higher than that of the CVC (91.7% vs. 66.7%, P=0.158).[10] However, because of the small sample size, there was no statistical difference in the success rate of the first attempt between the two groups. We also found that the main reason for conscious patients to refuse participation was the worry about the pain associated with IO insertion. Therefore, this multicenter randomized controlled study was conducted to compare the success rate of the first attempt and the pain score in establishing IO access and CVC in Chinese critically ill patients.
METHODS
Study design and setting
A clustered randomized controlled trial was carried out in eight hospitals in Beijing, China. The eight hospitals were Peking University Third Hospital, Peking University People’s Hospital, China-Japan Friendship Hospital, Beijing Friendship Hospital, Beijing Jishuitan Hospital, Beijing Haidian Hospital, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing Luhe Hospital (Beijing Jingmei Group Hospital). The eight hospitals were randomly divided into the IO group or the CVC group. From April 1, 2017 to December 31, 2018, each center consecutively included 12 patients who needed emergency vascular access according to the inclusion criteria. After informing the patient or his/her family about the risks and obtaining signed informed consent forms, we established IO access or CVC according to the measures allocated by the patient’s center. Drugs or fluids were administered through the established pathway. The center grouping was implemented by SAS 9.0 software, and the randomized grouping scheme was entrusted to the Clinical Epidemiology Research Center of Peking University Third Hospital. We obtained written informed consent for all enrolled patients. The treatment protocols were carried out in accordance with the principles of the Helsinki Declaration.
Participant selection
Inclusion criteria were: (1) older than 18 years old; (2) need to establish vascular access immediately; (3) unsuccessful attempts (two times) to establish peripheral venous access.
Exclusion criteria were: (1) unwillingness to participate in clinical trials; (2) fracture of the puncture site; (3) arthroplasty of the punctured joints; (4) infection of the puncture site.
Operators of IO access and CVC
Operators worked in the emergency departments. Operators were trained specialists and well-experienced in resuscitation. Before the commencement of the study, operators were trained in a 2-hour education program outlining the use of the IO device with instructional videos and subsequent hands-on training. Each operator practised using IO devices on the adult intraosseous bone models as much as he or she felt needed. When each operator felt sufficiently adept and confident in using the IO device, the sessions ended. All operators had more than one year of experience with CVC.
Instruments for IO access and CVC
IO access was performed with a spring-loaded driven device named Adult Bone Injection Gun (BIG, PerSys Medical, WaisMed Ltd., Lod, Israel). This single-use device weighs approximately 83 g with a “pull-out” safety latch and a safety stopper mechanism. For an adult patient, the device contains a 15G (1.8 mm) stainless cannula that is 25 mm in length with an adjustable insertion depth depending on the anatomic site. This device is suitable for the adult tibia, iliac bone, and femur, but not for the sternum. According to our protocol, the insertion site was the proximal tibia for IO access, and IO access was removed within 24 hours. After the time needed for emergency rescue, venous access should be established as soon as possible.
CVC was performed with a standard double- or triple-lumen 7-French catheter (Arrow International Inc., Limerick, USA), depending on the patients’ condition. The insertion site was determined by the operators according to the clinical situation, and CVC was removed within one month.
Primary and secondary outcomes
The primary outcomes were the success rate of the first attempt and procedure time of IO access or CVC. The success rate of the first attempt was defined as the successful administration of drugs or fluids via the newly established vascular IO access or CVC on the first attempt. Failure of IO access was defined as extravasation or unsuccessful (first) attempt of IO insertion. Failure of CVC was defined as an incomplete insertion or no possible advancement of the guide wire. However, more than one attempt to puncture a central vein was not considered as failure. The procedure time was defined as the duration of opening the packaging of the IO device or CVC set, preparation of the access set and patients’ insertion sites (including disinfection and draping), insertion procedure of the IO device or CVC cannula itself, assembling the access set, and the first successful administration of the drugs or fluids through the newly established vascular access. An independent observer with a stopwatch recorded the time of the procedure time.
Secondary outcomes included complications and operator satisfaction with devices used. All patients were followed up for two weeks. During the two-week observation period, possible complications were recorded, including malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haemothorax, pneumothorax, venous thrombosis, and vascular access-related infection. The operator satisfaction with devices used was rated using visual analogue scale (VAS) in which 0 implied that the device was not user-friendly, and 10 implied the highest user-friendliness. If the patient was conscious, the pain score associated with IO or CVC insertion or infusion would be recorded. The pain score was recorded using VAS in which 0 implied that the patient did not feel pain and 10 implied that the patient felt the worst pain. Baseline data, including age, sex, height, weight, and diagnosis, were recorded subsequently if they were not available on admission.
Statistical analysis
Data were analyzed using the SPSS software package version 22.00 (SPSS Inc., Chicago, USA). All quantitative data were tested for a normal distribution using the Kolmogorov-Smirnov test. Normal distribution data were expressed as mean±standard deviation. Non-normal distribution data were expressed as the median and 25% to 75% interquartile range. Normal distribution data were analyzed using independent sample t-test. Abnormal distribution data were analyzed using non-parametric tests. Qualitative data were expressed as frequencies and percentages. Qualitative data were analyzed using the Chi-square test or Fisher’s exact test. A P-value <0.05 was considered significant.
The sample size was calculated using PASS 11 (NCSS, LLC, Kaysville, Utah, USA). Based on the preliminary experimental results, the success rates of the first attempt were 92% for the IO group and 66% for the CVC group. To detect a difference between the two groups with 80% power, we used two-sided testing at the 5% level and an intraclass correlation coefficient of 0.001 with four clusters per group, and nine patients per cluster were needed. Considering a 20% design effect, 12 patients were needed per cluster.
RESULTS
A total of 96 adult patients who received IO access or CVC from eight hospitals were enrolled in the study, with 48 patients in each intervention group. Follow-up was possible for all 96 patients.
Characteristics of patients
A total of 63 men and 33 women, aged 20 to 95 (on average 65.6±17.1) years, were included. The IO insertion site was the proximal tibia. CVC was achieved in 29 internal jugular veins, 15 subclavian veins, and 4 femoral veins. There were no statistically significant differences between the two groups regarding gender, age, or body mass index. The main injury mechanism was shock, including cardiogenic shock, hypovolemic shock, and septic shock. Other injury mechanisms were poisoning and gastrointestinal bleeding. Isolated cases of cerebrovascular diseases, severe burn, and aortic dissection were reported in this study.
Success rates of the first attempt, procedure time, and operator satisfaction with the devices used
The overall success rate of the first attempt was 70.8% (68/96) for all patients. The success rate of the first attempt was 91.7% for IO access and 50.0% for CVC (P<0.001). Four IO procedures failed at the first attempt, and 24 CVC procedures failed at the first attempt, requiring at least one more attempt. The procedure time was statistically significant between IO access and CVC (52.0 seconds vs. 900.0 seconds, P<0.001). There was no statistically significant difference between the two groups regarding operator satisfaction with the instruments used (8.0 vs. 8.0, P=0.064).
Pain score
During this study, 32 patients were conscious, including 12 in the IO group and 20 in the CVC group. There was no statistically significant difference between the two groups regarding the pain score associated with IO or CVC insertion (5.5 vs. 3.0, P=0.091). Moreover, there were statistically significant differences between the two groups regarding the pain scores associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044).
Complications
Other than the above-mentioned unsuccessful access procedures on the first attempt following IO or CVC, no further complications were detected. In particular, no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haemothorax, pneumothorax, venous thrombosis, or vascular access-related infection was observed.
DISCUSSION
IO access has a long history and can be traced back to 1922.[11] IO access is established with different devices, including the First Access for Shock and Trauma, EZ-IO, and BIG. In China, BIG and EZ-IO have been approved by the National Medical Products Administration. BIG is compact, easy to carry, and widely used. Since 2013, performing IO access has been included as a standardized resident training in the USA. However, there is no relevant content covering IO infusion in Chinese medical textbooks and standardized resident training. In China, although the guidelines for CPR (preliminary draft) in 2009 recommended that IO access was suitable for all age groups, IO access should only be established if it is impossible to establish peripheral venous access for CPR.[7] The guidelines do not include a clear operation process, which is inconvenient to promote the use of IO. At present, there is no government quotation for IO devices in Beijing, which makes the purchase of IO devices difficult. All these reasons limit the development of IO access in China.
This prospective randomized multicenter study was the first to compare IO access and CVC in adult Chinese emergency patients. In this clustered randomized controlled trial, our results showed that the IO group had a significantly higher success rate of the first attempt than the CVC group (91.7% vs. 50.0%, P<0.001), and the mean procedure time was significantly shorter for the IO group than for the CVC group. Our results were in line with previous findings and demonstrated that IO access could be an alternative procedure to establish vascular access in emergency situations. Moreover, the adult BIG and CVC devices were user-friendly.
The success rate and the time needed for achieving vascular access are vital in an emergency setting. Multiple previous observational studies, which were not randomized controlled studies, demonstrated that IO access outperformed PIV access and CVC in the success rate of the first attempt and procedure time in emergency situations.[12-17] Ross et al[12] described 2,601 patients who received IO access and 55 patients who received PIV access in the setting of out-of-hospital cardiac arrest. The mean time from arrival at the patient’s side to the administration of the first dose of epinephrine was 5.0 minutes for the IO group and 8.8 minutes for the PIV group (P<0.001). The first IO success rate was 95.6%. Paxton et al[13] published their experience of 29 IO access cases, 57 PIV access, and 5 CVC during emergency room resuscitation. The mean time to access with good flow in the IO group was 1.5±1.1 minutes, which was significantly shorter than those in the PIV access (3.6±3.7 minutes, P<0.001) and CVC (15.6±6.7 minutes, P=0.006) groups. The success rate of the first attempt in the IO group was 80.6%, which was higher than those in the PIV access (73.3%) and CVC (20.0%) groups. Leidel et al[14] published a study of 50 patients with impossible PIV. IO access and CVC were performed simultaneously in each patient. The success rate of the first attempt was significantly higher for the IO group than for the CVC group (85% vs. 60%, P=0.024), and procedure time was significantly shorter for the IO group than for the CVC group (2.0 minutes vs. 8.0 minutes, P<0.001). In our study, the success rate of the first attempt and procedure time for the IO group were similar to those of Paxton et al[13] and Leidel et al.[14] In our study, the procedure time of CVC group was close to that reported by Paxton et al, while the success rate of the first attempt was higher than that recorded by Paxton et al,[13] which may be related to the small number of patients in the CVC group. In addition, the procedure time for the CVC group in our study was different from the results of Leidel et al,[14] which may be related to the operators’ experience and the severity of the patients’ disease. Although differences were noted in the results of these studies, they suggest that the IO access may be more suitable for critically ill patients needing vascular access than the CVC.
Besides the success rate and the mean procedure time, we also recorded the pain score. Our results showed that pain scores associated with infusion were significantly higher in the IO group than in the CVC group. However, there was no statistically significant difference between the two groups regarding the pain score associated with IO or CVC insertion. Paxton et al[13] investigated pain scores associated with insertion and infusion, and found that VAS pain scores were higher in the IO group, with a mean pain score from insertion of 4.5±4.2 and a mean pain score from fluid or medication infusion after lidocaine administration of 3.8±4.1. The VAS pain scores averaged 0.9±1.4 with PIV insertion and 1.0±1.7 with CVC insertion in patients with a Glasgow Coma Scale (GCS) score of 15. These results indicated that pain management during IO access in conscious patients was important. In addition, 2% IV preservative-free lidocaine was effective in limiting or alleviating IO infusion pain. The duration of the anesthetic effect varied between patients. Repeat doses of lidocaine may be necessary to maintain the anesthetic effect.
Regarding complications following IO access, the rate of adverse events was low.[18-20] Some prospective studies of IO access that included 553 adults did not describe any complications.[21,22,23] Early literature reported an infection rate of 0.6% in 4,270 cases of IO access to the sternum or tibia in children.[24] The complication rate for CVC was 15%-20%, and complications included malposition, arterial puncture, hematoma, pneumothorax, venous thrombosis, and catheter-related infections.[25-29] In our study, no IO- or CVC-related complications were detected.
Limitations of the study
There were several limitations in this study. Our study focused on the success rate of the first attempt of IO access or CVC. The sample size was too small to show the difference in the incidence rate of complications between the two groups. Whether IO access can improve the prognosis of patients is unclear. Further clinical trials with larger sample size and a longer follow-up period are recommended to answer these questions.
CONCLUSIONS
IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments. IO access is more successful on the first attempt and requires significantly less time than CVC. However, pain scores were significantly higher in the IO group than in the CVC group. Thus, it is necessary to give adequate doses of lidocaine before IO infusion if the patients are conscious. IO access can be used as an alternative method to quickly establish vascular access in emergency situations.
ACKNOWLEDGEMENTS
The authors would like to thank Ji-hong Zhu, Guo-qiang Zhang, Bin Zhao, Dong-ming Yu, Xin-yan Zhang, Ye Zhang, and Feng-jie Li for their assistance in the collection of data.
Funding: The study was supported by the Capital Clinical Characteristic Applied Research Project (z151100004015118), the Fostering and Exploring Project of Key Clinical Projects in the Peking University Third Hospital (BYSY2014006), and the Health Science Promotion Project of Beijing (TG-2017-83).
Ethical approval: This randomized study was approved by the ethics committee of the Medical Science Research Institute of Peking University Third Hospital (IRB00006761-M2016210).
Conflicts of interests: There is no conflict of interest.
Contributors: YYL and YPW contributed equally to this study. All authors made an individual contribution to the writing of the article, including design, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, and manuscript editing.
Reference
Prospective evaluation of peripheral venous access difficulty in emergency care
DOI:10.1007/s00134-007-0634-y
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PMID:17554524
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OBJECTIVE: Although frequently used and crucial in emergency care, peripheral intravenous access has been poorly documented. We examined whether criteria related to patient characteristics, underlying disease, devices, or environment were associated with difficult peripheral intravenous access. DESIGN AND SETTING: Prehospital prospective observational study. PARTICIPANTS AND MEASUREMENTS: For each peripheral intravenous access attempt a questionnaire was filled in until final success or procedure abandonment. This questionnaire included data on the patient, operator, disease, degree of emergency, cannulation, nature of fluid infused and the use of gloves, environment, and particular medical observations such as recent peripheral intravenous access and chemotherapy. Criteria associated with peripheral intravenous access difficulty were identified comparing successful and unsuccessful attempts. A total of 671 attempts at peripheral intravenous access in 495 patients were studied. RESULTS: The first attempt was successful in 368 cases (74%) and unsuccessful in 127 (26%). Final success was reported in all cases, including the use of central venous access in three cases. No abandonment was reported. Significantly correlated with a successful attempt were: the caliber of the catheter (OR 0.793), cannulation performed by a nurse specialized in emergency care (OR 3.959), lack of particular observations (OR 0.120), and a clean patient (OR 0.505). CONCLUSIONS: Peripheral intravenous access was achieved in 99% of the patients in out-of-hospital settings. Improved success rate was reported when attempts were performed by a nurse specialized in emergency care using a 16- or 18-G catheter in clean patients without a particular medical history.
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PMID:16271677
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STUDY OBJECTIVE: We assess the success rate of emergency physicians in placing peripheral intravenous catheters in difficult-access patients who were unsuccessfully cannulated by emergency nurses. A technique using real-time ultrasonographic guidance by 2 physicians was compared with traditional approaches using palpation and landmark guidance. METHODS: This was a prospective, systematically allocated study of all patients requiring intravenous access who presented to 2 university hospitals between October 2003 and March 2004. Inclusion criterion was the inability of any available nurse to obtain intravenous access after at least 3 attempts on a subgroup of patients who had a history of difficult intravenous access because of obesity, history of intravenous drug abuse, or chronic medical problems. Exclusion criterion was the need for central venous access. Patients presenting on odd days were allocated to the ultrasonographic-guided group, and those presenting on even days were allocated to the traditional-approach group. Endpoints were successful cannulation, number of sticks, time, and patient satisfaction. RESULTS: Sixty patients were enrolled, 39 on odd days and 21 on even days. Success rate was greater for the ultrasonographic group (97%) versus control (33%), difference in proportions of 64% (95% confidence interval [CI] 39% to 71%). The ultrasonographic group required less overall time (13 minutes versus 30 minutes, for a difference of 17 [95% CI 0.8 to 25.6]), less time to successful cannulation from first percutaneous puncture (4 minutes versus 15 minutes, for a difference of 11 [95% CI 8.2 to 19.4]), and fewer percutaneous punctures (1.7 versus 3.7, for a difference of 2.0 [95% CI 1.27 to 2.82]) and had greater patient satisfaction (8.7 versus 5.7, for a difference of 3.0 [95% CI 1.82 to 4.29]) than the traditional landmark approach. CONCLUSION: Ultrasonographic-guided peripheral intravenous access is more successful than traditional
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Survey on the knowledge, convince and application of intraosseous infusion in medical rescue team
Status quo study of the medical staff in intraosseous infusion in Beijing area
Establishing intraosseous access and central intravenous line placement in critically ill patients: a randomized controlled study
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Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins
DOI:10.1016/j.resuscitation.2011.08.017
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Introduction: Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins.
Methods: In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (>= 18 years of age) with inaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergency department.
Results: Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p = 0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0 min, p < 0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed.
Conclusions: IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC. (C) 2011 Elsevier Ireland Ltd.
Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study
DOI:10.1186/1754-9493-3-24
URL
PMID:19814822
BACKGROUND: For patients' safety reasons, current American Heart Association and European Resuscitation Council guidelines recommend intraosseous (IO) vascular access as an alternative in cases of emergency, if prompt venous catheterization is impossible. The purpose of this study was to compare the IO access as a bridging procedure versus central venous catheterization (CVC) for in-hospital adult emergency patients under resuscitation with impossible peripheral intravenous (IV) access. We hypothesised, that CVC is faster and more efficacious compared to IO access. METHODS: A prospective observational study comparing success rates and procedure times of IO access (EZ-IO, Vidacare Corporation) versus CVC in adult (>/=18 years of age) patients under trauma and medical resuscitation admitted to our emergency department with impossible peripheral IV catheterization was conducted. Procedure time was defined from preparation and insertion of vascular access type until first drug or infusion solution administration. Success rate on first attempt and procedure time for each access route was evaluated and statistically tested. RESULTS: Ten consecutive adult patients under resuscitation, each receiving IO access and CVC, were analyzed. IO access was performed with 10 tibial or humeral insertions, CVC in 10 internal jugular or subclavian veins. The success rate on first attempt was 90% for IO insertion versus 60% for CVC. Mean procedure time was significantly lower for IO cannulation (2.3 min +/- 0.8) compared to CVC (9.9 min +/- 3.7) (p < 0.001). As for complications, failure of IO access was observed in one patient, while two or more attempts of CVC were necessary in four patients. No other relevant complications, like infection, bleeding or pneumothorax were observed. CONCLUSION: Preliminary data demonstrate that IO access is a reliable bridging method to gain vascular access for in-hospital adult emergency patients under trauma or medical resuscitation with impossible peripheral IV access. Furthermore, IO cannulation requires significantly less time to enable administration of drugs or infusion solutions compared to CVC. Because CVC was slower and less efficacious, IO access may improve the safety of adult patients under resuscitation in the emergency department.
Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies
DOI:10.1097/CCM.0000000000000942
URL
PMID:25768683
OBJECTIVES: Intraosseous access is a rapid and effective route of fluid and drug administration. Its use has been proven in emergency medicine, pediatrics, and the military. We aimed to assess its performance and utilization against landmark-guided central venous catheter placement during inpatient medical emergencies. DESIGN: Prospective observational study. SETTING: Eight hundred fifty-six-bed urban teaching hospital. PATIENTS: Adult inpatients requiring central venous access during medical emergencies. INTERVENTIONS: Intraosseous device training was added to standard central venous catheter training beginning in February 2012. Intraosseous were used as primary access in cardiac arrests and secondary access if central venous catheter placement failed during noncardiac arrest emergencies. An online survey was conducted among intraosseous and central venous catheter operators to assess their experience and any barriers to use. MEASUREMENTS AND MAIN RESULTS: Seventy-nine adults had central access placement from February 2012 to July 2013. Sixty were during medical emergency team calls, and 19 were cardiac arrests. Thirty-one received intraosseous device, and 48 received a central venous catheter. First-pass success was significantly higher for intraosseous than for central venous catheter (90.3 vs 37.5%; 95% CI, 80-101 vs 24-51; p<0.001). Mean placement times were significantly shorter for intraosseous than for central venous catheter (1.2 vs 10.7 min; p<0.001). There were a total of 33 intraosseous versus 169 central venous catheter attempts with fewer attempts on average per patient during intraosseous placement (1.1 vs 2.8; p<0.001). There were three intraosseous-related complications and 22 central venous catheter-related complications. Our survey showed high satisfaction with intraosseous training and operation. Among the barriers cited, timely intraosseous kit acquisition was most common. CONCLUSIONS: It is feasible to incorporate intraosseous use during medical emergency team calls. Intraosseous had significantly higher first-pass success rates and faster placement compared with central venous catheters. Intraosseous operators reported high satisfaction and confidence in its use. Prospective randomized studies comparing intraosseous and central venous catheter are warranted.
Clinical application of intraosseous infusion in adult emergency patients
Cerebral fat embolism after intraosseous infusion
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Deltoid compartment syndrome: a rare complication after humeral intraosseous access
DOI:10.1097/GOX.0000000000001208
URL
PMID:28203508
We present a case of a 65-year-old woman who developed a delayed deltoid compartment syndrome after resuscitation via humeral intraosseous access. Initially she was treated conservatively but then was taken emergently for a fasciotomy. After confirming the diagnosis with compartment pressures, a 2-incision approach was employed and a large hematoma was evacuated from the inferior margin of the anterior deltoid. The rest of the deltoid was inspected and debrided to healthy bleeding tissue. Her fasciotomy wounds were left open to heal on their own due to her tenuous clinical condition. At most recent follow-up, she had full range of motion in her shoulder and no residual pain. Our unique case study is the first documented incidence of upper extremity compartment syndrome after intraosseous access. Additionally, our case supports using humeral access only as a second-line option if lower extremity access is not available and prolonged vigilant monitoring after discontinuing intraosseous access to prevent disastrous late complications.
Needle break: complication and management of intraosseous vascular access
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PMID:4025988
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Substantial difficulties can be encountered when establishing rapid intravascular access in critically ill children. The historic technique of tibial intraosseous infusion is presented as an alternate intravenous route in children less than 3 years old. Review of the literature reveals this technique to be a rapid, reliable method with an acceptably low complication rate. Substances absorbed through the marrow, flow rates, technical difficulties, and complications are discussed.
Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study
DOI:10.1016/j.annemergmed.2006.04.015
URL
PMID:17052555
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STUDY OBJECTIVE: We compare real-time ultrasonographic guidance and the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting. METHODS: This was a prospective, randomized, clinical study performed in a tertiary ED between August 2003 and May 2005 on patients requiring central venous access. Ultrasonographically guided catheters were inserted under real time using the Sonosite ultrasonographic system with a 10 to 5 MHz 38-mm linear array transducer. Standardized data were collected on operator experience, method of insertion, reason for central venous access, and comorbidities. Outcome measures included successful insertion of an internal jugular vein catheter, number of attempts, access times, and complications. RESULTS: One hundred thirty patients were enrolled. Cannulation of the internal jugular vein was successful in 61 of 65 patients (93.9%) using ultrasonography and in 51 of 65 patients (78.5%) using the landmark technique, a significant difference of 15.4% (P=.009, 95% confidence interval [CI] 3.8% to 27.0%). Fifty of 61 (82.0%) of the successful ultrasonographically guided catheters were inserted on the first attempt compared with 36 of 51 (70.6%) of the successful landmark catheters. Mean access times to venipuncture and successful insertion were 138 and 281 seconds by ultrasonographic guidance and 132 and 271 seconds by the landmark technique. There was a 10.8% complication rate, with 11 complications (16.9%) in the landmark group and 3 (4.6%) in the ultrasonographic group, a difference of 12.3% (95% CI 1.9% to 22.8%). CONCLUSION: Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.
Continuous B scan ultrasound guided post-traumatic sub-periosteal orbital hematoma drainage: An advantage over routine needle drainage procedure. World
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Central venous catheterization
DOI:10.1097/01.CCM.0000260241.80346.1B
URL
PMID:17414086
OBJECTIVE: To provide current information related to central venous catheterization. DESIGN: Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications. RESULTS: Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections. CONCLUSIONS: Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.
Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database. Am
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